Pablo Bravo, Ricardo Carvajal

LEARNING OBJECTIVE

We describe the usefulness of this access in a pediatric patient of 14 years, with a critical airway secondary to a large mass in the anterior mediastinum that compresses the central and peripheral airways, with intolerance to supine decubitus with severe hypoxemia despite Mechanical Ventilation (MV)

INTRODUCTION

The use of central venous catheter (CVC) is a necessary procedure in critically ill patients.

During the last time the puncture of the Brachiocephalic Vein (BCV) has achieved greater popular with the use of Ultrasound (US).

This approach allows visualize the vessel in longitudinal axis and to perform the puncture in plane. Researches have demonstrated safe technique in pediatric and neonatal patients, especially in patients with respiratory and hemodynamic compromise.

Usually for any jugular or femoral access the patient should be in a supine or mild fowler position, but in patients with airway compromise secondary to extrinsic compression, the above can produce severe respiratory deterioration.

OBJECTIVES

We describe the usefulness of this access in a pediatric patient of 14 years, with a critical airway secondary to a large mass in the anterior mediastinum that compresses the central and peripheral airways, with intolerance to supine decubitus with severe hypoxemia despite Mechanical Ventilation (MV) at positive pressure.

CASE REPORT

Child, 14 years old, history one month with cough, expectoration, respiratory distress, multiple consultations, including Thorax Radiography (X – ray) with rounded image in “Right Hilus” interpreted as pneumonia and treated with antibiotic, in addition to supine decubitus intolerance and shortness of breath sensation.

She went again to pediatric emergency and after evaluating a new x-ray, she took a tomogram: “a great mediastinal mass, with compression of superior mediastinal venous structures with complete occlusion of the left brachiocephalic vein, associated with jugular vein thrombosis and possibly subclavian on the same side, with trachea and bronchial sources displaced and narrowed.

Compression of superior mediastinal venous structures with complete occlusion of the left brachiocephalic vein, associated with jugular vein thrombosis and possibly subclavian on the same side, with trachea and bronchial sources displaced and narrowed.

She was transfer to PICU: for fever and suspected of infection, antibiotic is started, pericardial window for moderate pericardial effusion and mass biopsy is performed in Operating Room: she presented severe hypoxemic (saturation 80% – Fio2 100), returns to serious PICU desaturating, without secretions in endotracheal tube.

She is placed in head position of 70-80% almost sitting recovering saturation to 100%. Due to the need for central access for the management of tumor lysis syndrome and antibiotic treatment, the right supraclavicular approach was decided (left with venous thrombosis due to left brachiocephalic trunk occlusion by mass).

The operator is placed on the right side of the head, with a linear transducer, BVC is visualized, a puncture on the plane at the second attempt and a Seldinger technique with introduction of CVC 5 FR (triple lumen Arrow). She connected MV with sedation with fentanyl and Propofol, started of Corticoids, didn’t present tumor lysis, and extubated after 10 days after mass reduction with better tolerance to 30 grade head position.

In patients with airway compromise with secondary collapse to extrinsic compression, with risk of respiratory collapse when trying to put the patient in supine decubitus. The supraclavicular access allows a safe position for the patient and comfortable for the operator for the installation of central venous access.

This route for central access to be safely guided and without risk of further respiratory deterioration in this type of patients with critical airway.